Severe obstructive sleep apnea lessens esketamine effects in veterans with PTSD

Key takeaways:

• Veterans with greater apnea-hypopnea index scores saw less improvement with esketamine for PTSD.
• This outcome may be combatted with obstructive sleep apnea screening and treatment before using esketamine.

WASHINGTON — Veterans taking esketamine for PTSD had less improvement in symptoms when they had high obstructive sleep apnea severity at baseline, according to an abstract presented at the American Thoracic Society International Conference.

“Our findings suggest that untreated obstructive sleep apnea (OSA) may interfere with effective esketamine treatment on PTSD symptoms,” Brandon Nokes, MD, associate physician diplomate at University of California, San Diego, and colleagues wrote. “As such, screening and treating OSA prior to esketamine treatment may be a targetable intervention for improving clinical outcomes.”

Nokes and colleagues analyzed 24 veterans (mean age, 48 years; 20.8% women) who suffered with symptoms of PTSD and received esketamine (Spravato, Janssen Pharmaceuticals) to see the impact OSA severity, or apnea-hypopnea index (AHI) scores, have on the PTSD treatment.

To be included, patients had to have completed a Type III home sleep test, a PTSD Checklist for DSM-5 (PCL-5) and have tried a minimum of two different medications for depression or PTSD 2 years before the study with no improvement.

For the first 4 weeks of intranasal esketamine treatment, veterans received the dose twice a week. A once-a-week dose was given to patients after this timeframe (mean total doses, 8.3).

Researchers assessed changes in PSTD symptoms using PCL-5 scores, which were obtained each time a patient received esketamine, and tracked improvements or declines in these scores during the treatment through growth curve modeling.

After adjusting for age, researchers evaluated how dosage number and baseline AHI scores influenced PCL-5 scores.

At baseline, the mean PCL-5 score of the total cohort was 50.7, and the mean AHI score was 14.8 events per hour.

With every esketamine dose, PCL-5 scores significantly decreased, signaling improvement in PTSD symptoms (B = –0.95; P < .001), according to the abstract.

However, when factoring in a patient’s baseline AHI score, those with scores that indicated greater OSA severity demonstrated fewer changes in PCL-5 scores over the increasing number of esketamine doses (P = .005).

“The relationships between OSA severity, esketamine and PTSD symptoms is likely complex and requires future research to better understand the effects of CPAP, OSA endotypes and the possible effects of esketamine on upper airway collapsibility,” Nokes and colleagues wrote.